ACCIDENT REPORT California Fair Services Authority

ACCIDENT REPORT California Fair Services Authority

(Other Than Motor Vehicle) P.O. Box 15518, Sacramento, CA 95852-0518 (Retain Copy For Your Files)

CFSA Member Fair: Date (m/d/yy): Name and Title of Employee Completing This Report: Telephone:

Name and Title of Employee With Best Knowledge:

Location on Grounds: Date and Hour of Accident:

Was This Solely and Totally a Fair Sponsored/Controlled Event?: Yes No

Fully Identify Any Other Party Involved: (Carnival Operator, Sponsor, Exhibitor, Concessionaire)

Attach Copy of Contract and Certificate of Insurance (Except for Carnivals) If SEP - Copy of Receipt

INJURED PARTY

Name: (Last, First, Middle Initial) Address: (Street, City, State ZIP Code)

Telephone: Date of Birth: Participant? or Patron?

Nature and Extent of Injuries: (Be as Specific as Possible) Forward Copy of Any First Aid or EMT Report. (Accident description on reverse)

PROPERTY DAMAGE

(Not State Property)

Name of Property Owner: (Last. First, Middle Initial) Telephone: Address: (Street. City. State ZIP Code)

Description of Property, Nature and Extent of Damages: (Be as Specific as Possible)

WITNESSES

Name of Witnesses: (Last, First, Middle Initial) incl. other employees Address: (Street, City, State ZIP Code) Phone:

1.

2.

3.

4.

The SECOND page of this form must be completed.

NOTE: Do Not Delay Filing Report. Any Missing Information Should Be Sent Later, With Injured Parties

Name.

This is a CONFIDENTIAL report to provide information for use by legal counsel in the event a claim is filed against the State or fair. Under no circumstances should information be given to anyone except law enforcement officers, State officials, or persons representing CFSA.

(Rev. 7-1-95)

DESCRIPTION OF THE ACCIDENT

This section MUST BE COMPLETED fully! (A map or diagram of fairgrounds with site marked would be of assistance.)

Use additional space for diagrams or continuation of accident comment. Attach any available photographs. Photographs are especially requested in slip and fall or trip and fall accidents. Photographer's name, date and time taken and brief description of photo written on back of each picture.

This is a CONFIDENTIAL report to provide information for use by legal counsel in the event a claim is fled against the State or fair. Under no circumstances should information be given to anyone except law enforcement officers, State officials, or persons representing CFSA.